Incident investigation·April 15, 2025

LPA Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the incident involving Resident 1 (R1) that took place at the facility on December 20, 2024. LPA met with Administrator (AD) Ashiman Gill and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, staff roster, staff schedule, R1’s emergency contact information, R1’s physician’s report dated November 1, 2023, R1’s resident appraisal dated September 13, 2021, R1’s Physician order review (prescription list), facility surveillance camera footage from December 20, 2024, photographic evidence of R1 from December 21, 2024, Kaiser Permanente medical records dated December 20 to 24, 2024, R1’s after visit summary records dated December 26 and December 31, 2024. The investigation revealed following, The Director of Resident Engagement (DRE) Alyssa Herris led an engagement activity for residents on December 20, 2024, around 3:00 pm. The activity consisted of making a dried resin floral coaster. R1 was one of five participants. Two staff members were present during the activity. There were two bottles of Epoxy Resin (glue) that were mixed and poured in a red solo cup for residents to use in making the coaster. The DRE reported that putting resin in a cup was typical whenever they had a similar activity. The DRE admitted to placing the cup of resin on the table next to R1 and turned away from R1 to redirect another resident. R1 picked up the cup and started to take a few sips. The DRE turned and was facing R1 but was talking to another resident. The DRE saw R1 holding the cup by their mouth, so they went to R1 and took the cup away from R1. This information was verified by surveillance camera footage. R1 then stated, “I don’t want any more of that.” The DRE immediately notified the facility’s Director of Health Services (DHS) Elizabeth Retts. The DRE and DHS gave R1 some water and contacted the Nurse (N1) to assess R1 at 3:27pm. N1 reported that R1’s vital signs were normal. Poison control was called at 3:31 pm. Poison control advised staff to call 911 if R1 fails to eat and drink or if they start vomiting. 10 to 15 minutes later R1 had difficulty talking, became dizzy and R1 started to vomit. Staff called 911 at 3:53 pm. At approximately 4:00 pm the paramedics arrived and R1 was transported to St. Jude Medical Center. R1 was transferred from St. Jude Medical Center to Kaiser Permanente Irvine at 5:18 pm. R1 was hospitalized at Kaiser Permanente from December 20, 2024, to December 24, 2024. R1 suffered chemical burns on their tongue and lips. R1 was diagnosed with Acute hypoxemic respiratory failure and Angioedema (swelling in throat) due to a toxic substance. R1 was prescribed a puree diet, speech therapy and home health visits after their discharge. R1 had follow up appointments on December 26, 2024, and December 31, 2024, to check on their recovery. The facility reported the incident to the Agency on December 21, 2024. R1 was interviewed but could not recall the incident or their hospitalization. R1 ingested a toxic substance that led to Acute hypoxemic respiratory failure and Angioedema (swelling in throat). R1’s physician report shows; R1 has Mild Cognitive Impairment, their mental condition consisted of confusion and disorientation. R1 was noted to being able to follow instructions and communicate their needs. R1’s appraisal and medical records noted R1 has Dementia. The DRE reported that the resin, that was poured in the cup was from 2 different bottles of resin that contained different types of resin. Each bottle of resin had a different warning. Bottle 1 labeled epoxy resin A and bottle 2 labeled epoxy resin B. Bottle 1’s warning states, “causes skin irritation, causes serious eye irritation, may cause an allergic skin reaction, do not get in eyes. Do not get on skin.” Bottle 2’s warning states, “harmful if swallowed, harmful if contact with skin, causes serious eye damage. Do not swallow. Do not get in eyes.” The DRE poured a small amount of resin from each bottle in the cup and then put the cup on a table next to R1. The resin in the cup is a poisonous substance and the cup was unattended as the DRE was attending to another resident when R1 drank from the cup. After the incident R1 was hospitalized. R1 was discharged from the hospital to another facility. During the course of the investigation, the Department obtained sufficient evidence to substantiate, that during the incident the facility failed to ensure that poisonous substances which could pose a danger to residents are not left unattended if outside the locked storage. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.